Birmingham Women's NHS Foundation Trust seeks to provide women with a service that is of highest quality, safe and exceeds the needs and expectations of women and their families. The publication of the "Place of Birth Study" (2011) provided impetus for the development of a long desired dedicated home birth team (HBT) that was planned to meet the aspirations of both women and the Trust. The benefits of taking this approach could potentially produce positive results in three key areas:
- Women's experiences of maternity services,
- Financial aspects of maternity services: multiparous women require less interventions when they deliver at home,
- Capacity and resources within the hospital as more elements of care would be undertaken outside the physical environment of the hospital.
This service will help to implement the NICE recommendations on choosing planned place of birth within CG190 Intrapartum care.
Aims and objectives
Strategically the need for reconfiguration of maternity services is clear to move low risk women out of the hospital setting into the community. Health outcomes will be improved and there will be improved use of financial resource to direct to the areas of higher need such as the increase in complexity of deliveries as a direct result of increased public health concerns such as obesity. This predicted redirection of finances from within what is a limiting tariff certainly contributed to Birmingham Women's successful funding bid with Birmingham South Central Clinical Commissioning Group (CCG).
Evidence suggests that by the end of the three year pilot the service would begin generating an income allowing for the redirection of tariff to under resourced areas of maternity. The homebirth team (HBT) was commissioned in 2013 by the Clinical Commissioning Group and funded by Birmingham South Central commissioning group with an aim of the service of increasing the homebirth rate in Birmingham Women's Hospital from 0.3% to 3% in 3 years (a total of 240 women pa by the end of year 3). The recruitment of staff for the service started in October 2013. All staff had completed the Trust induction period and underwent compulsory mandatory training, which was accomplished by the end of March 2014. Active recruitment of women into the service commenced at beginning of April 2014.
Reasons for implementing your project
Previous provision for home birth rested with the four community midwifery teams, who maintained a twenty-four /seven on call service for women. This proved to be unsatisfactory as these staff were part of the hospital escalation policy and therefore had to work in the hospital when activity level was high. The ramifications of this were two fold; neither women nor midwives had the confidence in the homebirth service being available 24/7. Therefore the midwives did not actively promote the service as they were concerned women were likely to be disappointed. Historically management of staffing decisions have had to prioritise resources into the hospital. The direct impact of this was that few women had their babies at home, only 23 in 2013, which is less than 0.31%.
Methods and innovation
Before the team were in post the consultant midwife and other senior managers reviewed other Homebirth models of care used across the country. As a starting point the best fit was the model that Kings College Hospital NHS Foundation Trust has used successfully for the past 5 years, achieving a homebirth rate of 5.5%.
It has been reported that midwives suffer from burn out when providing a 24/7 on-call homebirth service with a continuity of care model. Being aware of issues faced by other home birth teams, BWH sort to be innovative in its staffing design it, decided to use maternity assistants/support workers to be the second on call birth attendant, once they had been through the appropriate training. This would help maintain a service that is sustainable and affordable. This training has resulted in the formation of a bespoke foundation degree in partnership with Birmingham City University. This has been largely funded by Health Education West Midlands LETC. In addition to increasing the academic achievements of the wider maternity workforce we are also providing a sustainable career structure to support staff.
At the outset the planned structure for the on calls was from 08:00-20:00 (1st and 2nd) and 20:00-08:00 (1st and 2nd) with additional day shifts covering clinics. Although this structure has been followed the model is proving to be unrelenting on staff. The main reason for this has been that there have been delays in training the MSW's. It is expected that once these are trained the on call system will work more smoothly. Use of MSW's at home birth is a relatively new approach and will be reviewed further.
How did you implement the project
A new dedicated homebirth team was recruited using values based recruitment methods. 50% came from within the trust and 50% were external applicants. Initially in the business plan forwarded to the CCG the costs were based on 6.6FTE midwives support by 5.8 FTE MSW (Maternity Support Workers). There was an assumption that the MSW's could have in-house training and assume the role of a second birth attendant. However subsequent to the bid being accepted, The Cavendish Report (2013) had done a comprehensive review of MSW training and recommended that MSW's receive training through an Higher Education Institution (HEI) if they were going to undertake tasks previously performed by a qualified midwife. Following this recommendation the decision was made to educate the MSW's through the local HEI. This was a short term barrier, as the on call cover immediately reduced capacity by 5.8 FTE (almost 50%).
A new curriculum was written and implemented and for this additional funding was granted through the local CCG, at a cost of 45K per year. The long term benefit will be a better skill mix of one midwife and one MSW at a homebirth, allowing the homebirth service to be more responsive and sustainable in the longer term.
Before the team were in post the consultant midwife and other senior managers travelled across the country to speak with other homebirth teams with regards to the model of care that they used. As a starting point the best fit was the model that Kings were using, the structure is made up of two on calls from 08:00-20:00 (1st & 2nd) and 20:00-08:00 (1st & 2nd) with additional day's shifts covering clinics. Although this is working and within the first eight months, the HBT rate has increased by over 300%, the model has proved unrelenting on staff. Ironically the model is particularly arduous when there are quiet periods, as they have the inconvenience of being on call (which they get paid a 9.5% enhancement on salary) but gain no hours if they are not called.
It is difficult to say, whether this will work better as activity increases. Kings have used it successfully for 5 years and have a homebirth rate of 5.5%. The funding from the CCG was calculated by the finance team based on actual costs. This separate funding stream has been beneficial and has allowed the project lead to undertake projects that may not have been approved if it was to go through mainstream funding. The funding is to be paid in instalments providing annual targets are met.
In 2013, the year before the Homebirth Team was set up there were 23 planned homebirths. From the go-live date to October 2014 the HBT received 212 referrals of which 173 (82%) were accepted to have a home birth. Of these 139 received care until they were in labour and 61 resulted in a homebirth out of a possible 79 attempted. Therefore 18 women had to transfer to hospital during their labour. The remaining women had not delivered by the time of writing the report. Water was the most commonly used analgesia with a 48% water birth rate. 34% of women did not use any analgesia in labour. Data is displayed in key findings at the end of the report attached to this example as supporting material.
We are working with The West Midlands CLAHRC delivered by University of Birmingham to formally evaluate the service. There first report is due to be published in January 2015.
One innovation that is currently under review as there are difficulties maintaining sustainability is the approach of sharing the cost of the pools with the families. A very successful marketing strategy has been our pilot birthing pool project. Women booking with the homebirth team are entitled to receive a birth pool voucher which entitles them to ¾ discount off the cost of a birthing pool. This has proved to be popular and the homebirth team water birth rate is 48%.
- Undergo an external evaluation that will lead to further developments and improvements
- This project was a pilot for three years - it is currently at its half way mark and therefore plans to mainstream the service are afoot.
- Develop a domino service that will work in tandem with the home birth service for women who don't want to give at home.
Key learning points
- Have a clear strategic plan, and utilise project methodology to allow for agreement and monitoring of measurable targets in collaboration with the team and managers.
- Recruit the right people, from the project lead to each team member, who are committed to the project and are able to embrace change.
- Do not underestimate the degree of flexibility of mind needed when setting up a new service that is trying to change the norm.
- Celebrate the regular team successes.
- Set realistic goals, which can be movable if the situation indicates and therefore not viewed failures in a negative light.
- Embrace failure, this has enabled the team to try new, innovative ideas around recruitment, most of which have worked; others have not been so successful and therefore stopped.
- Employ an experienced leader.
- Do not underestimate the training needs of existing qualified midwives. As 21st century midwives we have become deskilled at homebirth because with a national average of 2.46% it is no longer the norm. The skill set required is different and requires midwives to be confident in working alone delivering autonomous intra-partum care. One of the things we have done is to conduct 'emergency skills and drills training' in the home environment
- Culture is key! The perception and culture over the last 50 years has been that all mum's and babies do better if they birth in hospital. One of our biggest challenges, therefore, was to win hearts and minds. The team approached this in numerous ways: lots of face to face contact, going to children's centres, homebirth groups and hosting tea parties which are an informal way for families to meet other families who have had or are interested in having a homebirth and to meet other midwives and maternity support workers. Leaflets have been sent to every GP surgery. The team are active on social media and we ensure we are at the forefront of all Trust-wide publications.
Funding by Birmingham South Central Clinical Commissioning Group.